'Every Oncologist Is a Geriatric Oncologist'

Zosia Chustecka

August 14, 2014

As cancer is a disease of aging, with the majority of diagnoses and deaths occurring in patients over 65 years of age, every oncology practice will have a fair proportion of elderly patients, maybe as much as 55% to 60% of the total. "So every oncologist is a geriatric oncologist, whether they realize it or not," said Stuart Lichtman, MD, attending physician at the Memorial Sloan Kettering Cancer Center's 65+ clinical geriatrics program and professor of medicine at the Weill Cornell Medical College in New York City. "It's just the nature of the disease."

Which is why the new series of reports on geriatric oncology, published in a special issue of the Journal of Clinical Oncology,is pertinent to every practicing oncologist, he suggested in an interview with Medscape Medical News.

Dr. Stuart Lichtman

Dr. Lichtman was a coeditor for the special issue, which was published online July 28. It contains a collection of 18 articles focused on many aspects of delivering care to elderly patients with cancer, with some consensus and expert opinions in areas where data from clinical trials are lacking, as older age is an exemption from enrolment.

An overview article explains that the series will bring "clinical oncologists up to date on evidence-based treatment recommendations for older patients with cancer."

Geriatric oncology is a relatively new field, formalized only in 2000 with the establishment of the International Society of Geriatric Oncology. Before that, "there were really only a handful of us," he said, although there had been a few significant meetings before that, such as the Perspectives on Prevention and Treatment of Cancer in the Elderly in 1983, and an international meeting on Cancer in the Elderly in 1994, which he attended. Many of the issues that were raised at those early meetings are still being discussed today, Dr. Lichtman commented.

Perhaps the most important, and what he describes as the "mantra" of geriatric oncology, is the discrepancy between chronological age and physiological age. Some 80 year olds are fit and healthy and can withstand rigorous surgery, as well as radiation and chemotherapy, but others who are the same calendar age are much frailer, even before taking into account comorbidities.

"There are some 80 year olds who can be treated with the same standard of care that you would give to a 50 year old," Dr. Lichtman commented, but in other cases, that treatment may have to be modified or even changed, depending on the functional age of the patient.

This is where a comprehensive geriatric assessment comes into play. As explained in the report by Hans Wildiers, MD, PhD, from University Hospital Leuven in Belgium, and colleagues, these are tools that involve multidimensional and interdisciplinary diagnostic processes that focus on determining an older person's medical, psychosocial, and functioning capabilities (e.g., activities of daily living). Such a tool can identify age-related problems that are not picked up by a routine history and medical examination, (for example, fatigue and nutritional problems). It can also influence oncology treatment decisions, such as lowering the amount of prescribed drugs, reducing chemotherapy intensity, or initiating supportive care.

One element is a tool that specifically assesses the potential for toxicity, developed by Arti Hurria, MD, from the City of Hope Hospital in Duarte, California, and colleagues (J Clin Oncol. 2011;29:3457-3465). The idea here is that "really very simple and straightforward clinical parameters — hemoglobin, creatinine clearance — and very simple history taking and geriatric assessment" can be used to make valuable predictions about an older person's likelihood of experiencing severe toxicity from chemotherapy, Dr. Lichtman explained.

Tolerating Chemotherapy

Several of the reports in the series discussing various tumor types note that while elderly cancer patients can often obtain the same benefits from chemotherapy as younger patients, they are often more susceptible to adverse effects. "In general maybe, yes, but this is not always the case," Dr. Lichtman noted, and there are instances where older patients tolerate chemotherapy better than younger ones. A case in point is nausea and vomiting, which older patients seem to have less problem with when compared with younger patients. "Whether it's neurological, or stoicism, or other issues that go on in life, it's not clear.... Maybe people reach a certain age and seem to not find such a problem with certain things," he said.

Emotionally there is a different perspective when you have cancer at 80 years old than when you are diagnosed at 40 years old, he pointed out. The cancer has come at a different point in the whole lifetime experience, and this influences how you react to the diagnosis and how you react with people, including those involved in your treatment, he commented. "The disease is fitting into their lives in a different way, and the way they manage these situations is different," he emphasized, "and it's not always worse."

This difference is emphasized in the report focused on cancer survivorship, which discusses the implications for an aging population of life after treatment. The authors, led by Julia Rowland, PhD, from the Office of Cancer Survivorship at the National Cancer Institute in Bethesda, Maryland, highlight "the tendency for older adults to frame the cancer experience differently from younger persons." They also note that "comparative studies suggest that older survivors manifest better psychosocial adaptation to cancer than younger survivors."

Dr. Lichtman commented that a big risk factor for toxicity is lack of social support, and this needs to be taken into consideration. Of course, this applies to patients of all ages, but elderly patients may not have the social network that a younger person is likely to have, he said. If the patient wakes up at 2 AM with fever, is there someone there to drive the patient to the emergency department for treatment for febrile neutropenia? What about organizing the medicines to make sure a treatment regimen is followed correctly?

"I always say that geriatric medicine is the ultimate in personalized medicine because you have to get to the nitty gritty of all of these issues," he said. "It really needs to take into account a lot of other factors, and not just the disease and dose of drug." As well as comorbidities and kidney functioning, this personalization needs to take into account what else is happening in the patient's life, he said, recalling how he rescheduled treatment to allow to a patient to see her grandchild board the school bus for the first time.

He finds working with elderly patients rewarding, and said they often have a good attitude: "They really appreciate the fact that you are not giving up on them because they are old."

A few months ago at the American Society of Clinical Oncology (ASCO) annual meeting, Dr. Lichtman was awarded the B.J. Kennedy Award for Scientific Excellence in Geriatric Oncology. During the presentation of the award, former ASCO president Sandra Swain, MD, commented: "For more than 2 decades, Stu Lichtman has devoted his career to providing quality care to the undeserved and undertreated older patients with cancer."

J Clin Oncol. Published online July 28, 2014.

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